I for one applaud the opportunity for clinicians to be leaders in the drive to influence the evolving role of clinical documentation in alignment with the original goals cited below. The current iteration of EHR systems is defensive in nature and serves to block any litigious endeavor concerns resulting in a documentation process that obscures the basic tenets of improving patient outcomes.

The primary goal of EHR-generated documentationshould be concise, history-rich notes that reflect the informationgathered and are used to develop an impression, a diagnostic and/or treatment plan, and recommended follow-up. Technology should facilitate attainment of these goals in the most efficient manner possible without losing the humanistic elements of the record that support ongoing relationships between patients and their physicians.

Policy Recommendations for EHR System Design to Support 21st-Century Clinical Documentation

1. EHR developers need to optimize EHR systems to facilitate longitudinal care delivery as well as care that involves teams of clinicians and patients that are managed over time. 2. Clinical documentation in EHR systems must support clinicians' cognitive processes during the documentation process. 3. EHRs must support “write once, reuse many times” and embed tags to identify the original source of information when used subsequent to its first creation. 4. Wherever possible, EHR systems should not require users to check a box or otherwise indicate that an observation has been made or an action has been taken if the data documented in the patient record already substantiate the action(s). 5. EHR systems must facilitate the integration of patient-generated data and must maintain the identity of the source.

The EHR should remain the domain of the clinicians and not be manipulated to serve the needs of multiple stakeholders with varying objectives in their content and output. The Medical Informatics Committee of the ACP has developed this review of clinical documentation processes to suggest a better outcome to help capture the burgeoning data sources that will become relevant to patient care in the years to come.

Observe, record, tabulate, communicate.--Sir William Osler

Communication was the primary goal of early patient records. A clear and concise record of patient presentation, diagnoses, and treatment to be consulted by any member of the care team either at the present or future but beginning in the early 1900s the data capture became formalized. Template standardization and structure forms replaced the more narrative prose in communicating clinical findings and decisions regarding care.

Patient centricity and the need for real world evidence to inform point of care clinical decisions will also challenge data collection and integration into EHR systems. As information becomes bi-directional systems will need to regulate and control the provenance of data sources and privacy concerns of transmission and evaluation of patient-related data. The opportunities to engage the business needs around this enterprise are not trivial. I believe that there will be a return of the narrative and unique voice of the clinician perspective as guidance into the capture and utility of structured and unstructured data.

Future blogs will address how this evolution can be managed both at the patient level and for the entire care pathway for a variety of therapeutic needs. You can send any questions or comments to bonny@dataanddonuts.org